IMPLEMENTATION OF THE WHO PROGRAMME CST IN BRAZIL 1

Implementation of the WHO Programme “Caregiver Skills Training” in Brazil

Implementación del Programa de la OMS “Capacitación en Habilidades para

Cuidadores” en Brasil

Implementação do Programa da OMS “Treinamento de Habilidades de Cuidadores” no

Brasil
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Abstract

This research evaluated the implementation, in Brazil, of the program "Caregiver Skills

Training" (WHO), directed to caregivers of 2-to-9-year-old children with Neurodevelopmental

Disorder. Qualitative study, conducted through 2 focus groups, whose data were processed

following Descending Hierarchical Classification, by software IraMuTeQ®. 5 categories

emerged from the caregivers' group (n=7) that concluded the training: development of the child's

skills; challenges of inclusion and treatments; understanding; support for caregivers; changes in

caregivers’ behavior. 5 categories identified at Master Trainers' group (n=4): achievements;

method; organization and planning; field activity; supervision. The results demonstrate that the

implementation of the program at this country is feasible, acceptable, and relevant, and that the

training meets local needs. Positive changes at caregivers' management and support network

creation were observed, in addition to improvement in social interaction, communication, self-

care and children’s behavior, after CST.

Keywords: autism spectrum disorder, neurodevelopmental disorders, mental health programs,

caregivers.

Resumen

Este estudio evaluó la implementación, en Brasil, del programa “Capacitación en Habilidades

para Cuidadores” (OMS), dirigido a cuidadores de niños (2-9 años) con Trastorno del

Neurodesarrollo. Estudio cualitativo, realizado mediante 2 grupos focales, cuyos datos fueron

procesados según clasificación jerárquica descendente, software IraMuTeQ®. Del grupo de

cuidadores (n=7) que completaron la capacitación surgieron 5 categorías: desarrollo de

habilidades del niño; desafíos de inclusión y tratamientos; comprensión; apoyo a los cuidadores;

cambios en el comportamiento de los cuidadores. 5 categorías identificadas del grupo de

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“Master Trainers” (n=4): logros; método; organización y planificación; actividades de campo;

supervisión. Los resultados demuestran que la implementación del programa en Brasil es

factible, aceptable y pertinente, y que la capacitación satisface las necesidades locales. Se

observaron cambios positivos en la gestión de los cuidadores, creación de una red de apoyo,

mejoras en la interacción social, comunicación, autocuidado y comportamiento de los niños

después del CST.

Palabras Clave: trastorno del espectro autista, trastornos del neurodesarrollo, programas de salud

mental, cuidadores.

Resumo

Este estudo avaliou a implementação, no Brasil, do programa “Treinamento de Habilidades de

Cuidadores” (OMS), voltado para cuidadores de crianças (2-9 anos) com Transtornos do

Neurodesenvolvimento. Estudo qualitativo, realizado a partir de 2 grupos focais, cujos dados

foram processados segundo classificação hierárquica descendente, pelo software IraMuTeQ®.

Do grupo dos cuidadores (n=7) que completaram a capacitação emergiram 5 categorias:

desenvolvimento das habilidades das crianças; desafíos da inclusão e tratamentos;

compreensão; apoio aos cuidadores; mudanças nos comportamentos dos cuidadores. 5

categorias foram identificadas do grupo focal dos “Master Trainers” (n=4): conquistas; método;

organização e planejamento; atividades de campo; supervisão. Os resultados demonstraram que

a implementação do programa no Brasil é viável, aceitável e relevante, e que a capacitação

atende às necesidades locais. Foram observadas mudanças positivas no manejo dos cuidadores,

criação de rede de suporte, melhora na interação social, comunicação e autocuidado das

crianças, após o CST.

Palavras Chave: transtorno do espectro autista, transtornos do neurodesenvolvimento, programas

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de saúde mental, cuidadores.

Introduction
The prevalence of Neurodevelopmental Disorders (NDD), especially Autism Spectrum

Disorder (ASD), has increased considerably over the past few decades. Due to their significant

influence on child development and on the quality of life of family members, they represent a

major public health challenge. Although ASD is an incurable chronic condition, it is treatable.

Early intensive intervention in the first years of life, when important changes in cognitive, motor,

social, and language abilities take place, is recommended (Victorine et al., 2006). Studies

indicate that protective environmental factors can modify and reduce the effects of biological

risk factors, allowing children to overcome some difficulties in early childhood, as long as there

is adequate intervention and children receive early environmental stimulus (Valiati, 2014).

However, intensive professional treatments are costly, causing children with these

conditions to lack access to care in low- and middle-income countries. In Brazil, the

socioeconomic characteristics of the majority of the population make the treatment

recommended for ASD unaffordable. As an alternative, the current literature indicates that

caregivers can learn techniques to promote skill development in their children with suspected

NDD, and there is evidence that children benefit greatly from these interventions. Therefore,

parent training is a viable and effective alternative (Tekola et al., 2020) in low resource settings.

Given the epidemiological data, which points to an increasing prevalence of NDD

(especially ASD), the scarcity of interventions and professionals available in low- and middle-

income countries, as well as the therapeutic potential of caregiver-mediated interventions, the

Department of Mental Health and Substance Use of the World Health Organization (WHO), in

partnership with the Autism Speaks foundation, developed a pioneer programme, called
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Caregivers Skills Training (CST), based on scientific evidence, findings of systematic literature

reviews and meta-analyses (Hamdani et al., 2017). The CST is intended for caregivers of

children aged 2 to 9 years in developing countries; additionally, it aims at sustainability by

building on locally available resources and services. Ideally, CST should be part of a cohesive

network of care services available to families of children with DD or NDD. It is designed so that

non-specialist professionals, who are present in basic healthcare networks, can be instructed to

deliver the programme to caregivers.

The training aims to assist parents in promoting skills, reducing disruptive behaviors and

improving the child's quality of life. It also promotes a better understanding and acceptance of

DD and NDD, as well as of the necessity of adjustments to life with the child, which helps

improve the psychological well-being of family members. In addition, the programme intends to

reduce the stigma against people with developmental disorders, resulting in greater social

inclusion.

The CST is a manualized programme, taught by a pair of facilitators who are primary

care professionals with no specialization (such as nurses, nurse technicians, and social workers),

trained and supervised by Master Trainers. In turn, Master Trainers are professionals specialized

in developmental disorders, qualified and certified by the WHO; they are at the top of the

pyramid and are responsible for transferring technical knowledge to facilitators in a cascade

learning model.

The CST consists of nine weekly group meetings, with an approximate duration of 180

minutes each and with 30-minute intervals. Facilitators also conduct three home visits to each

family, with individualized instructions that last approximately 60 minutes each. Visits take

place before the first group session, in the week of the fourth one, and after the last meeting.
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This methodology is currently being tested in more than 30 countries; this study is part of

the transcultural adaptation and validation of the programme to the Brazilian context. This phase

of the research aims to evaluate the feasibility and acceptability of CST in Brazil. This pre-pilot

study evaluated the first application of the programme. In this first step, the Master Trainers

delivered the training; however, after the full implementation, facilitators should become

responsible for delivering the training, which would ideally take place in a community

environment. The methods adopted in the research in general and in the first training cycle in

particular followed the design proposed by the WHO.

Method

This is a qualitative and observational descriptive study with prospective data collection.

This study is part of the validation process of the WHO’s programme CST, and consists in the

qualitative analysis of the first capacitation cycle realized in Brazil. The pre pilot program was

conducted from July to September 2019, in the city of Curitiba, Brazil.

Participants

The study sample is comprised of patients referred to the public healthcare service in the

city of Curitiba, southern Brazil, at the outpatient clinic Enccantar, which specializes in the care

of children and adolescents from 0 to 17 years of age with suspected or confirmed ASD. At the

time of the selection of subjects, the target population (people in Enccantar’s waiting list)

consisted of 190 children.

Non-probabilistic convenience sampling was systematically applied to select participants,

whose caregivers met the following inclusion criteria: a) being the caregiver of a child from 2 to

9 years of age with a suspected diagnosis of NDD, referred for specialized psychology, speech

therapy, or occupational therapy treatment in the outpatient clinic Enccantar; b) being able to
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attend group sessions and receiving home visits; c) agreeing to participate in group training; d)

living in Curitiba; e) signing the Consent Form; f) participating in at least 75% of the training,

including group sessions and home visits. Exclusion criteria for caregivers were: a) the child

being under multidisciplinary treatment at the time of inclusion in the study; b) having genetic

syndromes and/or multiple (sensory and motor) disabilities; c) not providing sufficient

information for research analysis; d) withdrawing consent.

Among the 190 children who were waiting for assistance at the clinic, 38 families were

contacted by phone by the Master Trainers, following the chronological order of referral. From

these, 10 families were interested in participating in group training and were able to attend the

training according to the schedule proposed by the professionals.

The 4 Master Trainers who participated in the study were specialized professionals,

trained and certified by the WHO in Brazil. Two Master Trainers were responsible for

coordinating the groups, whereas the other two were observers.

Instruments

The groups followed the two guides provided by the WHO, which present the guidelines

for the conduction of the conversation circle: one directed to the professionals and the other to

the caregivers. The professionals’ guide consists of questions aimed to investigate the

perceptions of Master Trainers about the experience of guiding the household visits and group

sessions as well as the main facilitators and barriers related to the application of the program.

The caregivers’ guide presents questions about the parents’ experience in the program, including

the learning process and involvement on the strategies presented, suggestions about

improvements and adaptations of the intervention, material used and acceptability of the

program’s content and strategies.

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Procedures

The qualification occurred in 9 (nine) weekly group meetings, each one lasting

approximately 180 minutes, of which 30 consisted of intermission. The meetings happened at the

outpatient clinic Enccantar (located at Curitiba’s downtown) and were conducted by the Master

Trainers, trained and qualified by the WHO. The professionals also realized 3 (three) household

visits for each family, at their residences, performing individual orientation, with an approximate

duration of 60 minutes. Both the household visits and the group sessions were accompanied by a

member of the research team. The focus groups had an approximate duration of 60 minutes and

were conducted at the outpatient clinic Enccantar, after the conclusion of the qualification.

Data Collection

Data collection followed the implementation schedule of the WHO. Data comprises

qualitative measures obtained through two focus groups (FG), one with caregivers who

completed the training (n = 7) and one with Master Trainers (n = 4), conducted after the last

training session and directed by the researchers, following the guidelines provided by the WHO.

FG is considered one of the most efficient instruments on identification and translation of the

participants’ perception about a subject, as it offers interaction through dialogue, sharing of

mutual experiences and awareness (Nóbrega et al., 2016). Before the beginning of both groups,

general rules of operation of this methodology were presented, such as: presentation, attendance

and the purpose of the recording equipment, general objective of the discussion, guidelines such

as the importance of everyone talking, talking one at a time and being prepared to interruptions

from the moderator in order to assure that every topic is approached, reliability and secrecy.

Data Analysis

Qualitative data analysis was performed using the focus groups’ audio recordings, which
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were transcribed to text by a professional transcription service (Transcribeme) and subsequently

checked for accuracy. Text transcriptions were inserted in the software program IraMuTeQ®

(Interface for R pour les Multidimensional Analyzes de Textes et de Questionnaires) and

analyzed based on the Descending Hierarchical Classification (DHC).

It is relevant to highlight that using the software is not a method of data analysis, but a

way to process them, therefore, it does not conclude this analysis, since interpretation is

essential and it is the researcher’s responsibility (Kami et al., 2016).

At this research, the texts are the set of answers of the participants of each FG (Master

Trainers and caregivers) to the questions presented by the researcher at the conversation circle.

After the FG’s transcription, the answers were organized in two files and originated two corpus

of analysis. At the Master Trainers’ FG’s corpus three texts were formed, which correspond to

Master Trainers’ answers to the set of questions presented. At the caregivers’ corpus, five texts

were formed to the set of the participants’ answers.

Textual data organization and analysis, composed by the transcription of the focus

groups, followed the methodological accuracy of thematic categorical analysis purposed by

Bardin (2011), which includes three phases: pre-analysis, categorical analysis and interpretation.

The system of categories was submitted to researchers’ analysis. From this procedure, some

adjustments were made to reach the minimum agreement index among judges of 70%.

Ethical Considerations

This research was approved by the Human Research Ethics Committee of the Complexo

Hospital de Clínicas of Federal University of Paraná (CAAE n: 02994018.7.3001.0101), as well

as by the Ethics Committee of the Health Department of Curitiba City Hall (report number

3.158.989), in accordance with Resolution No. 466, December 12th, 2012, of the National
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Health Council.

Results

The sociodemographic characteristics of the 10 families who started the training are

shown in Table 1. Families 1, 4, and 8 withdrew from training. 70% of the families completed

the programme, with an average session attendance of 86.9%.

Table 1

Caregivers and Children’s Sociodemographic Characteristics

Family Caregiver Education Status Work Ethnicit Child sex/ Diagnosis

age (years) level profile y age age
(months) (months)
1 Mother, High school Marrie Yes, White Male, 49 ASD, 34
47 d fulltime
2 Mother, High school Living No White Female, 48 ASD, 46
42 - with a
incomplete partner
3 Mother, High school Single No White Male, 39 ASD, 34
36
4 Mother, High school Living No Brown Male, 67 ASD, 66
25 with a
partner
5 Mother, High school Marrie Yes, White Female, 62 ASD, 47
40 d fulltime
6 Mother, 34 High school Single No White Male, 87 ASD, 67

7 Mother, Higher Marrie Yes, White Male, 40 ASD, 36

32 education – d fulltime
incomplete

8 Mother, High school Living No White Male, 57 ASD, 55

32 with a
partner
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Family Caregiver Education Status Work Ethnicit Child sex/ Diagnosis

age (years) level profile y age age
(months) (months)

9 Mother, High school Marrie Yes, White Male, 84 ASD, 54

39 d fulltime
10 Mother, Higher Living Yes, White Male, 58 ASD, 39
25 education with a parttime
partner

Note. Caregivers and children’s sociodemographic characteristics

For the qualitative analysis, the caregivers FG generated a corpus formed by 5,302 word

occurrences, and five texts comprised of 150 text segments, of which 106 (70.67%) were

considered in the DHC. We identified five themes based on this corpus:

(1) Development of the child's skills (19.8%): theme in which participants expressed their

perceived progress in the child's skills. They reported how the strategies learned in CST

improved their children’s vocabulary, communicative and social skills, and also improved their

management of their children’s challenging behaviors, as shown in the following excerpt:

C1 (…) when I ignore his behaviors, he goes back to his regular behavior and continues

talking. He has even developed more of his speech. (...) he is interacting more with

the others at school. I am very happy with this progress (…) I started to deal with him

better. Before, these things would throw me off and be enough to make me feel like

leaving the house … he wanted to get my attention all the time. Now that has changed.

(2) Challenges of inclusion and treatments (17.9%): difficulties experienced by mothers,

delayed diagnoses, the scarcity of guidelines, and lack of access to treatments were mentioned.

In regards to education, caregivers also reported that they notice the difficulty professionals face

in making the necessary adjustments for the child’s needs and in supporting the family. Here is
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an excerpt on this theme:

C2 (…) I learned that my daughter has no label, she has her own way, and everyone has

their own way (…) When G. entered nursery school, the Principal thought that she would

only adapt to a part-time schedule. She has a problem with food. And the Principal, from

day one, looked at my face and said that, in her school, children don’t go part-time.

(3) Understanding (17%): in this theme, mothers talked about the changes brought by

CST in the way they perceive and deal with their children’s difficulties, and how this new

understanding helped them to feel less guilty. They also reported feeling misunderstood by

family members and close people who had not had access to the knowledge and change process

provided by the training. Participants were able to reevaluate stigmas about neurodevelopment

delay and ASD that are still present in the community, as shown in the following excerpts:

C3 (…) the CST, the care they passed on to us, this important information about

preparing, caring, made me think differently. As a mother, as an educator, I need to

change my mindset, my way of acting.

C4 (…) my difficulty is in explaining that to people in a way that they can understand the

reasoning. That it is not a ritual, it is not a formality. Each child has their particularity,

although they do not look like an autistic person. People say ‘you have to do this’, ‘you

have to do that’. We have learned, and I would like others to do the same because it is

working. But for some people, often those close to you, there is a barrier for them to even

understand the way you are acting.

(4) Support for caregivers (21.7%): this theme shows that the training offered assistance

to caregivers and knowledge about NDD. It also taught intervention strategies and allowed the

development of a support network. This sense of support is illustrated in the following excerpts:
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C4 (…) when you arrive at CST, they say that they will help you and your kid, help you

understand how to ignore challenging behaviors, and how to be closer to each other. They

teach you step by step, task by task. It helps you see through the child's eyes. Some things

that are normal for you, but not for them. This is to help my daughter. No one can do it

better than me. For me, it is essential (…) for us to be able to help ourselves, as

caregivers, as mothers, to help in hard times.

(5) Changes in caregivers’ behavior (23.6%): the main focus in this theme is the

recognition process developed in the training. When listening to other mothers' reports and also

during dramatizations, participants were able to recognize ways of thinking and acting that they

did not perceive in themselves. This recognition triggered reflections and personal

transformations, including self-care, as exemplified in the following excerpt:

C5 (…) sometimes we think in a certain way, but we learn a little from each participant in

CST. We learn a little from each one, to try and do the same at home.

In the Master Trainers FG, the corpus comprised 2,533 word occurrences, generated from

3 texts that consisted of 71 text segments, out of which 60 (84.51%) were considered in the

DHC. Five themes were identified:

(1) Achievements (20%): the advances pointed out by the Master Trainers are related to

professional growth and improvement of themselves - in terms of knowledge, technique, and

experience - and also of participants. The professionals realized that the interventions

accomplished their objectives and that caregivers were effectively applying the strategies they

had learned, thus promoting the development of the child's skills and improving their well-being.

The following excerpts illustrate this theme:

M2 (…) the CST helped implement strategies with the children, the families felt more
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confident, less stressed, and their skills improved.

M4 (...) the changes we have seen are incredible (…) from the first to the last visit, you

have no idea of the difference it has made. To organize the space, to organize things, and

the empowerment of families. Caregivers arrived here feeling discouraged, not knowing

what to do. This group helps them have fun and feel empowered. The positive thing is

that the caregivers stopped being victims of their circumstances and have learned to own

them, even with all difficulties involved. None of them knew about those difficulties, but

they knew that they were able to walk, and knew about the network they formed (…) in

fact, we learned a lot, we learned to be humble and to stop judging and being prejudiced,

thinking that we know everything.

(2) Method (21.7%): this theme gathers excerpts that demonstrate the participants'

perception about the effectiveness of the programme’s method, and whether the content is

adequate, sufficient, and accessible. However, it also raises concerns about the way the materials

are arranged, as they felt it was difficult to synchronize the organization of the handouts (for

facilitators and caregivers) with content presentation in the sessions. Here is a segment that

exemplifies this theme:

M1 (…) it was difficult to get used to the material, the way the text material is laid out.

What was intended to be done in practice and what was only meant for us, facilitators.

Understanding the material took time and I think we will have to change that, because,

with the way the material is presented, it is very difficult, to learn and to convey (…) but

it was positive to see that this methodology works (…) so I was confident that what we

were talking about was working, they (caregivers) were not simply agreeing with what

we were talking about, they were doing it.

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(3) Organization and planning (13.3%): in this theme, Master Trainers emphasized the

importance of planning and mastering sessions before applying them. They were also concerned

about offering well-structured training to facilitators so that they would feel prepared to teach

CST. In addition, Master Trainers perceived the need to organize the best schedule to conduct

home visits, considering the distance between the caregivers' home and the training location, as

well as the workload that facilitators will have during the CST.

Another point that they raised was their perception that the recorded dramatization (in

video) works better than when performed live. These excerpts illustrate this theme:

M1 (…) we have to think about the home visits, the logistics, because it takes a lot of

time (…) think that people will have a workload, besides CST, at their workplace, we

have to think it through, where these people will be so that this is possible and accessible,

whether for caregivers to go to the CST or for the Master Trainer to make these visits.

M3 (…) we need to develop a more practical training format when training the new

facilitators in the group, because we finished the week without knowing how to do it, we

only had a general understanding (…) in the recording (video role-plays made for each

session) you can rewind, and direct what the caregivers observed (…) with the live role-

play you lose a lot, so the same video role-play standardizes the information for everyone

who participates. Having the role-play video ready and recorded makes it easier, you just

play the video.

(4) Field activity (21.7%): in this theme, Master Trainers singled out home visits and

practices carried out in the family context as the central point of the programme, due to the fact

these meetings accommodate for the particular characteristics of each family, their context, the

child's level of development, and the caregivers’ potential and difficulties. They perceive this
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factor undoubtedly contributes to setting appropriate goals and choosing appropriate teaching

strategies. Moreover, the visits create a bond between the family (caregiver and child) and the

coach/facilitator. This proximity and increasing confidence enhanced engagement and adherence

to the training. Here is a segment that exemplifies this theme:

M4 (…) the home visit, it was a game-changer, because on the first day we did it and

started the group, we learned more about each child that we had been talking about, I

can’t remember the names of the caregivers or the children, but I knew each one, and

then, as you talk about the CST and the strategies, you can see each child and adapt that

content to each one of them, so I think it becomes more practical and even easier for you

to give guidance to caregivers. It personalizes the group a little, it generates engagement,

the caregivers value it.

(5) Supervision (23.3%): this theme shows the awareness of Master Trainers about the

need for more and more systematic supervision. It addresses the concerns Master Trainers had

about the kind of supervision that they will provide to facilitators in the next phases. This aspect

was the main difficulty they pointed out in the implementation of CST, as shown in the

following:

M2 (…) we could have had more guidance on the steps that we should take. We do not

know how we will supervise others. We, the four Master Trainers, were a little lost at

times in how to direct the group. In the sense of knowing what the next step was, what to

expect. We were a little insecure, but we got together a lot. We studied the material

together, we practiced for many weeks, we learned about everything in the material. We

have some questions about when to supervise and how to do this process.

Figure 1 presents the analysis of the Master Trainers FG in a word cloud, allowing for
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quick visualization of the content. This type of analysis, performed in the IRaMuTeQ software,

generates a graphical representation according to the frequency of words, which are presented

in different sizes: the bigger ones at the center are more frequent and important in the corpus

(Camargo, 2013).

Figure 1

Word Cloud (Master Trainers FG)

Note. This figure shows the word cloud of the analysis of the Master Trainers Focus Group

content elements.

Discussion

The treatment of developmental delays and disorders from an early age can have

important impacts on the lives of children and their families. Unfortunately, in low- and middle-

income countries, these disorders are still little or late-diagnosed, and treatments are not very

accessible. This means that low-cost caregiver training, such as CST, has great potential for

implementation and dissemination in these contexts, in addition to representing possible life

changes for this part of the population.

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As of today, there are still few published studies on CST in other countries, since a large

portion of them are still in progress. Pre-pilot data from Ethiopia have been presented in

scientific articles, and studies from Kenya, Chile, Italy, and Hong Kong have been presented as

posters. Nevertheless, these published studies about the CST programme around the world

demonstrate the great relevance and acceptability of this methodology (Tekola et al., 2020;

INSAR, 2019; INSAR, 2018).

In this study, the qualitative analysis showed consistent initial results that are in line with

findings in other countries. The qualitative data confirm the perception of the Master Trainers

that the contents are presented in an intelligible way, which allowed caregivers to put them into

practice (theme 2), and that their participation and engagement increased during the training

(theme 1). Data from caregivers suggest that group sessions and home visits were well accepted

and did not involve socio-cultural barriers.

The results of this study also demonstrate that the implementation of the CST programme

in Brazil is feasible. Regarding practical issues, such as location, the Brazilian pre-pilot was

conducted in a specialty center in the central region of the city, similarly to Ethiopia's pre-pilot,

which took place in a clinical (hospital) and non-community setting. Participation and attendance

of participants in the training were satisfactory, and Master Trainers managed to conduct home

visits within their workload. However, Master Trainers (FG - theme 3) raised concerns about the

feasibility of future phases, as facilitators will have fewer hours fully dedicated to CST, and

home visits require time availability. They perceive the need for prior planning of home visits

and believe that proximity between the training site and the target population’s homes is an

important factor for both families and professionals, which makes employing the methodology

on a larger scale more feasible.

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In the qualitative interviews of the Ethiopian study, observers also mentioned practical

challenges related to home visits (Tekola et al., 2020). In preliminary results of CST trials around

the world, feasibility issues in home visits and video recordings (safety, travel, lack of time), as

well as the lack of childcare, are also mentioned as barriers to training (INSAR, 2019).

Some barriers regarding feasibility of application can be minimized with adjustments that

meet the practical difficulties brought forward by families. Offering care to the child during

training, adjusting the training schedule, and setting the location closer to families’ homes are

examples of actions that may increase participation in training. Some of these difficulties are

likely to be minimized when, once validated, the training occurs in community environments,

near caregivers’ residences.

Although the primary objective of this study was to assess feasibility and acceptability of

CST in the local Brazilian context, and not the impact of the programme on the children and their

families, there were significant improvements in the target population. For instance, we highlight

the improvement of children’s symptoms; the shift in caregivers’ perception; their improved

management of their child's difficulties; the increased self-confidence of caregivers; and the

creation of a support network among the families. On the other hand, we suggest that

improvements should be made to dramatizations, manuals, and supervision, as well as that

secondary caregivers should be included in the training.

Limitations

It should be noted that this study has some limitations. The main limitation is the low

number of participants. This research design, defined by the WHO, allows an exploratory study

of the caregivers’ and Master Trainers’ perceptions, but it does not allow analyses with statistical

significance. In addition, it was found that the educational level of mothers who participated in
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the pre-pilot study is higher than the national Brazilian average, and that the Master Trainers are

specialists who have knowledge and mastery of the techniques used. Thus, the results presented

here possibly do not represent those that will be found in future CST studies, which will occur in

community settings in different regions of the country, with a different population profile, and

will be directed by facilitators.

Conclusion

Our findings demonstrated that both the methods and the content of the CST programme

are acceptable to the target population and that its application in the Brazilian context is feasible.

Despite the preliminary nature of this study and its particular characteristics, the model of parent

training in the CST, composed of group and individualized sessions, seems to have positive

results. Parents learn skills to promote their child's development, become more aware of the

child's potentials and limitations, and thus become more empowered. However, it is still

necessary to measure the benefits of this training with a larger number of participants, using

standardized instruments, as well as to verify the quality of the training when taught by

facilitators. Therefore, the continuity of this research, in subsequent phases of implementation,

will provide better support for this programme to be delivered in the most appropriate way to the

Brazilian population. These findings in Brazil may also be relevant for countries with low

resources and similar sociocultural characteristics.

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